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What are the Patterns of Joint Involvement?
Psoriatic arthritis can affect the spine or other joints. Most people with psoriatic arthritis have swelling in joints outside the spine. In most of these people, more than five joints are affected.
Psoriatic arthritis may either occur in the same joints on both sides of the body ("symmetrical arthritis"). At the beginning of the disease, however, it is more likely to occur in different joints on either side of the body ("asymmetrical arthritis"). Some people only have swelling in the outermost joints, such as in the tips of the fingers or in the toes. In addition, the entire finger or toe may become painful and swollen, called a "sausage" digit.
Approximately 5 percent of people with psoriatic arthritis have arthritis only in joints of the spine, or spondylitis. This form of psoriatic arthritis usually affects the sacroiliac (sa-KROih-lee-ak) joints and joints in the lower back and neck regions. This leads to pain and stiffness in the buttocks, lower back, neck or along the spine. This may lead to restriction of back movement. Some people with psoriatic arthritis have both spinal involvement and joint involvement outside of the spine.
How is it Diagnosed?
To find out if you have psoriatic arthritis, your doctor will ask about your symptoms. He or she will then perform a physical examination. The examination can detect abnormalities of joints such as tenderness, swelling, pain on movement of joints, or limitations in joint movement. In addition, your doctor will look for evidence of psoriasis on the skin or changes in your fingernails and toenails. Your doctor also may perform some or all of the following tests:
- X-rays to look for changes in your bones and joints
- Blood tests to rule out other diseases, such as rheumatoid arthritis (RA).
- Joint fluid tests to rule out gout or infectious arthritis.
How is it Treated?
The goal of treatment for psoriatic arthritis is to reduce joint pain and swelling, control patches of psoriasis on the skin and slow down or prevent joint damage. Common treatments, including skin care, medication and exercise are described on the following pages.
Skin Care
- Keep your Skin from Becoming Dry
- Avoid using strong soaps.
- Use a lanolin cream or lotion. Your doctor may prescribe a glucocorticoid cream to control scaly skin patches.
- Use non-deodorant soaps.
- Put baby oil in your bath water.
- Use a humidifier in the winter.
- Try using a synthetic vitamin D3 derivative ointment.
- Try Light Treatment
- Light treatments such as those listed here should only be tried upon your doctor's recommendation.
- Sit in the sun for short periods of time.
- Try a UVB (type B ultraviolet light) treatment.
- Try a PUVA light treatment. This is a combination of the prescription medicine psoralen (SORE-ah-len), taken either in pill form or added to a bath, and type A ultraviolet light. You may need at least 20 to 30 treatments over several weeks.
- Try Special Cosmetics
Using special makeup can help conceal skin problems and make you feel better. Ask about special cosmetics at the cosmetic counter of any large department store. The cosmetic staff can teach you how to apply their products.
Medication
The benefits of the medications used to treat psoriatic arthritis include their abilities to help relieve joint pain and swelling and to help slow down joint damage. However, what works for you may not work for someone else with psoriatic arthritis. Take all medications as directed by your doctor and pharmacist.
Be sure to tell your doctor about all the prescription and over-the-counter (OTC) medications and/or herbal or dietary supplements you are taking. Taking some medications together may cause a bad reaction.
Nonsteroidal Anti-Inflammatory
Drugs (NSAIDS)
Nonsteroidal anti-inflammatory drugs, or NSAIDs (EN-seds), can help reduce joint pain and swelling. You may need to take NSAJDs for a few days or weeks or perhaps much longer, depending on your condition. Over-the-counter NSAJDs include aspirin, ibuprofen and naproxen sodium. Some NSAIDs are available only by prescription. Talk with your doctor about whether it is safe to take OTC medications in addition to the ones prescribed to you. Over-the-counter medications are often in lower doses and may con=1 pain, but they may not control inflammation.
COX-2s
COX-2 inhibitors, such as celecoxib (Celeb,vx), rofecoxib (Vioxc) and valdecoxib (Bextra), are NSAIDs that may be safer for the stomach. NSAIDs work by blocking the production of substances called prostaglandins (pros-ta-GLANdens) at the site of inflammation. All NSAIDs, inluding COX-2 inhibitors, occasionally can cause a decline in kidney function.
Tumor Necrosis Factor Inhibitors
The tumor necrosis factor (TNF) inhibitor etanercept (Enbrel) is approved by the FDA for reducing the signs and symptoms of active arthritis in adult patients with psoriatic arthritis. Etanercept is taken twice per week in 25-milligram (mg) injections underneath the skin in the thigh, abdomen or upper arm. You can inject the drug yourself or have the injections given by a partner or a caregiver. Etanercept can be used without methotrexate or in combination with methotrexate.
The most common side effects of etanercept include headache, upper respiratory infection and mild injection site reactions, such as itching and redness. If you develop symptoms of infection while using etanercept, call your doctor so you can receive proper evaluation and
treatment. Recent clinical studies have shown that another TNF inhibitor, infliximab (Remicade), also may have a role in treating psoriatic arthritis.
Etretinate
Etretinate is a vitamin A-like drug used to treat psoriatic arthritis. It usually is prescribed if other medicines have been unsuccessful. Etretinate is not recommended for children because it can interfere with bone growth. It can cause birth defects and must be used with birth-control measures in women to prevent pregnancy.
Glucocorticoids
Glucocorticoids are synthetic forms of cortisol, a hormone your body makes. Your doctor may prescribe glucocorticoid pills or creams, or may inject the medicine directly into muscles or painful joints. Oral glucocorticoids, such as prednisone, in low doses may be needed to manage widespread joint inflammation.
Disease-Modifying Antirheumatic Drugs (DMARDS)
Disease-modifying antirheumatic drugs (DMARDs) slow down the progress of chronic forms of inflammatory arthritis, including rheumatoid arthritis (ROO-ma-toyd ar-THRYtis) and psoriatic arthritis. They usually are slower acting and more powerful than NSAIDs. They work best if they are used before much damage from the disease has occurred. Your doctor must carefully monitor you when you take DMARDs.
Methotrexate
Methotrexate helps relieve joint pain, stiffness, and swelling. It also can improve psoriatic skin lesions. You must not drink alcohol if you take methotrexate. Taking folic acid can reduce some of the side effects.
Leflunomide
Leflunomide (Arava) has been shown to be helpful for the treatment of RA. It is as safe and effective as methotrexate. It is currently being studied for treatment of psoriatic arthritis.
Sulfasalazine
Sulfasalazine has been shown to be beneficial in treating people with psoriatic arthritis. Clinical studies have shown that sulfasalazine relieves joint pain, swelling and skin rash, and it may be used in combination with methotrexate. People who are allergic to medications containing sulfa cannot take sulfasalazine.
Cyclosporine
Cyclosporine suppresses the immune system. It is most commonly used to treat people who have had organ transplants. It has been shown to be effective in treating the skin and joint problems of psoriatic arthritis. Cost and side effects can be concerns when taking cyclosporine.
Azathoprine
Azathioprine also suppresses the immune system and helps to relieve joint pain, stiffness and swelling in psoriatic arthritis.
Hydroxych Ioroquine
Hydroxychloroquine is sometimes prescribed to treat psoriatic arthritis. There are several possible eye problems that develop with hydroxychloroquine. You should have an eye exam every six to 12 months while taking the drug.
Exercise
Exercise is an important part of your treatment. It can limit the pain and swelling of arthritis that can make your joints stiff. Exercise also can improve movement, strengthen muscles, improve sleep, strengthen the heart, reduce weight and improve physical appearance. Work with your doctor or physical therapist to develop an exercise program that's right for you.
Rest
Generally, a normal amount of rest and sleep will be sufficient to decrease fatigue and reduce joint inflammation. In a very few people, however, psoriatic arthritis may cause extreme fatigue. If this happens, you may need to rest more than usual during that time and learn how to pace your activities and use your energy wisely throughout the day. For more information about pacing your activities, request a copy of the Arthritis Foundation's brochure Managing Your Activities.
Heat and Cold Treatments
Heat and cold treatments can temporarily relieve pain and reduce joint swelling. Examples of treatments include soaking in a warm tub or placing a cold pack on the painful joint. Talk to your doctor or physical therapist about what treatments may be best for you.
Splints
Splints help rest your joints. They may be useful if you have joint inflammation or problems with joint alignment or stability. Using splints helps decrease joint pain, swelling and stiffness. Your doctor, physical therapist or occupational therapist can help determine the best splint for you and when you should wear it.
Surgery
Most people with arthritis will never need surgery. However, if your joints are severely damaged by arthritis or when other treatments don't lessen the pain, your doctor may recommend joint replacement surgery.
In this surgery, joints damaged by arthritis are replaced with artificial joints. Benefits of joint replacement include reduced pain and improved movement.
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